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Back  RFI # 574: Referring provider number

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Submitter

Description

For the 2310A loop (referring provider secondary info), we disagree with the imterpretation that, "OR", means required. Referring number is not required in order for us to pay claims. We need a name, OR, a number, but not both. We intrepret the IMP guide, with OR, as meaning name OR number required but not both.

Request this be reviewed and current compliance editing for this loop and segment be changed.

Response

This issue is explicitly addressed in guide 004010X098. The Referring Provider NM1 segment shows the name (NM103) as required. The NM104 first name is also required if the provider is a person. The NM108 and 09 elements are required by notes if the NPI or tax id is known. The Referring Provider Secondary Identifier REF segment note states "Required if NM108/09 in this loop is not used or if a secondary number is necessary to identify the provider." Therefore, it is not compliant with this guide to provider only a referring provider name or only a number. The name and at least one number (in either NM108/9 or the REF) is required, independent of whether or not your system uses both.
Submission 6/29/2007
Status Date 8/24/2007
Status F - Final
Primary References
Document 004010X098
Section3.1
Page288
Set ID2310A
Table2
Loop2310A
Segment IDREF